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Abstract

Background

Ergonomic and work stress interventions rarely show long-term positive effect. The
municipality participating in this study received orders from the Norwegian Labour
Inspectorate due to an identified unhealthy level of time pressure, and responded
by effectuating several work environment interventions. The study aim is to identify
critical factors in the interaction between work environment interventions and independent
rationalization measures in order to understand a potential negative interfering effect
from concurrent rationalizations on a comprehensive work environment intervention.

Methods

The study, using a historic prospective mixed-method design, comprised 6 home care
units in a municipality in Norway (138 respondents, response rate 76.2%; 17 informants).
The study included quantitative estimations, register data of sick leave, a time line
of significant events and changes, and qualitative descriptions of employee appraisals
of their work situation gathered through semi-structured interviews and open survey
responses.

Results

The work environment interventions were in general regarded as positive by the home
care workers. However, all units were simultaneously subjected to substantial contextual
instability, involving new work programs, new technology, restructurings, unit mergers,
and management replacements, perceived by the home care workers to be major sources
of stress. Findings suggest that concurrent changes induced through rationalization
resulted in negative exposure effects that negated positive work environment intervention
effects, causing an overall deteriorated work situation for the home care workers.

Conclusions

Establishment and active utilization of communication channels from workers to managers
are recommended in order to increase awareness of putative harmful and interruptive
effects of rationalization measures.

Keywords:

Background

Workplace interventions to reduce musculoskeletal complaints rarely achieve their
stated objectives or to the extent harmful work exposures are alleviated, such gain
tends to be nullified in the longer term. Westgaard and Winkel [1] summarized 59 systematic reviews of intervention studies within this subject area,
covering engineering and organizational interventions, interventions aimed at strengthening
individual resilience, and reviews considering implementation strategy. The overriding
finding was lack of evidence for positive effect on health or risk factors in the
longer term. This state of affairs has been noted by many researchers and is increasingly
ascribed to concurrent “natural changes”, i.e. on-going changes to workplace conditions
unrelated to the intended intervention, yet potentially affecting the intervention
outcome and thus considered “noise” when assessing work environment intervention effects
[2-8]. Consequently, researchers strongly stress the need for process evaluation as an
integral part of intervention evaluation studies [7,9-11], and for coincident changes to be integrated into intervention designs [5].

A general aim and thus a key intervention in both public and private enterprises is
a continuous effort to achieve reduced costs and improved quality of their output,
whether material goods or services. Such production system interventions or rationalizations
(term used in this paper) have a dominant influence on the design of organizations,
production lines and workplaces, and are frequently carried out with low priority
for worker health effects. Westgaard and Winkel [1] reviewed studies of rationalizations without a stated concern for worker health effects,
but nevertheless reporting work exposure or worker health data. Dominant negative
exposure and health effects of rationalizations were reported; however, negative effects
were to some extent alleviated by management procedures involving a resonant management
style [12], worker participation in the design of new production systems and in the rationalization
process, organizational support, and procedural justice. The authors posited that
on-going rationalizations were a major cause of poor outcome of worker health interventions,
and recommended that work environment concerns should be integral to the planning
of rationalization efforts, which is also the theoretical basis of the present study.
However, few studies provide specific information on the interaction between work
environment interventions and rationalization, with equal weight on documenting both
processes. The present study aims to contribute to such insight by documenting outcome
and processes in a setting where interventions for improved work environment are carried
out in an organization that simultaneously strive for production system efficiencies
in response to economic constraints.

This study is based on home care workers (HCWs) in a large municipality in Norway.
Like most enterprises, the home care services (HCS) has become an object of rationalization
measures [13,14]. Many studies report that this occupational group is exposed to several risk factors
at work and have health problems. Psychosocial work exposures (e.g. time pressure
[15-17], workload pressures [17], high levels of mental job demands [18]) and physical work exposures (e.g. poor ergonomic conditions [15,16,19]) have been identified as risk factors for the prevalent occurrence of musculoskeletal
pain for HCWs [19,20]. This also applies to the participants in this study [21]. In 2003 the municipality was served with a legally binding order by the Norwegian
Labour Inspectorate (NLI) to improve working conditions due to a high level of unhealthy
time pressure. The subsequent work environment interventions were duly carried out
by the municipality. At the same time, the HCS underwent several organizational changes
and other significant processes influencing work duties took place. The stated ambition
of the municipality was that the work environment interventions would improve risk
factors of time pressure and ergonomics, and further reduce sick leave. However, musculoskeletal
symptoms and sick leave remained high at the end of a 6-year observation period [21]. The present study, using a historic prospective mixed-method design, documents sick
leave development, here used as a work environment and health indicator, rationalization
measures and work environment interventions, and their effects as perceived by the
HCWs.

The specific aim of the study is to identify critical factors in the interaction between
the two processes, whereby putative positive work environment intervention effects
are reduced or eliminated by rationalization. The study setting is well suited to
explore this point: The NLI inspection and subsequent orders ensure that an intervention
for improved work environment has high legitimacy, and key stakeholders in the municipality
showed a genuine interest in achieving good work conditions for HCWs. Furthermore,
the HCS has been subjected to organizational changes to reduce costs, obtain more
efficiency and provide improved access to services, like most health care systems
in the industrial world [22-26].

Methods

The study has a mixed-method design by using a combination of quantitative estimations
(of perceived time pressure and evaluation of intervention effect), register data
of sick leave, documentation of significant events and changes, and qualitative descriptions
of employee appraisals of their work situation. The study is part of a larger longitudinal
study of factors contributing to an undesirable quality of work environment and sick
leave rate in the HCS.

Setting and case description: The HCS Campaign and subsequent Interventions

In 2002–2008, the NLI carried out a national campaign focusing on the work environment
in the HCS. The purpose of the campaign was to target occupational risk factors identified
by a national survey to be highly prevalent among HCWs: time pressure (characterized
as straining by 80% of respondents), ergonomics and violence/threats [27], and stimulate to actions that reduce such risk factors. In 2003 the municipality
in this study received orders from NLI due to a high level of unhealthy time pressure
and a high sick leave rate. The municipality was legally obliged to comply with NLI
orders, and responded by allocating NOK 14.5 mill (€2 mill). The anticipated result
of their interventions was reduced time pressure and lower sick leave of HCWs.

A project group with worker participation was established, and a model for risk assessment
was developed, comprising ten potential risk factors of time pressure (e.g. work organization,
patient characteristics, resources available, management, culture etc.) anticipated
to result in physical and mental complaints and furthermore sick leave. The model
served as basis for a thorough work environment survey involving all HCWs. A program
focusing on employee empowerment, skill upgrading and networking was established as
a process method to ensure worker participation. Employees at all units provided descriptions
and examples on risk factors of time pressure, and participated in defining intervention
content. Contributions were listed on flip-overs, further discussed and then written
in a formal document stating the identified risk factors, associated interventions,
person in charge of each particular intervention, due date and so on. Internal reports
point at work organization, patient characteristics, and lack of resources as the
risk factors mentioned most frequently across the units (not referred to due to anonymity).
In 2004–2006 interventions were carried out in local units to target unit-specific
risk factors of time pressure, and on municipal level to target common risk factors
for all units. Examples of local interventions included the establishment of a functional
template for work lists, clarification of appropriate expectations by patients, and
buying more cars and telephones. Common interventions for all units included the implementation
of a safety patrol to relieve stress due to alarms going off, a temporary staff recruitment
service to fill vacancies due to high sick leave, and the introduction of staff uniforms
to advance HCW professionalism. Also, the campaign and its corresponding actions have
generally motivated the municipality to ensure a continuous focus on work environment
issues for this professional group.

In 2008 NLI was pleased with the municipality’s efforts and closed the orders, implying
that the work situation would be improved for the targeted risk factors. In their
campaign evaluation report the NLI referred to this municipality as an example of
‘good practice’ in responding to orders given. However, HCWs in 2009 still seemed
exposed to several occupational risk factors, musculoskeletal health complaints, and
high sick leave rate [21].

Participants

At study start, the HCS of the municipality was organized in 11 geographically separate
home care units. Representatives of the municipal secretariat informed the unit leaders
about the project and 6 units signed up for participation. HCWs with employment fraction ≥ 50%
(181 participants) were included in the study. The final sample consisted of 138 respondents
(76.2% response rate to the questionnaire), of whom 89.8% were female. 77.5% had a
professional health care education as either Registered Nurse or Enrolled Nurse. Average
age was 42 years (range 20–64). Seventeen HCWs were selected as interview informants
through purposive sampling based on seniority (minimum 7 years) and employment fraction
(≥50%).

Procedure

Initial conversations were carried out with an inspector of the NLI, representatives
of the municipal secretariat and unit leaders to gain insight in the NLI campaign,
and aspects of the HCS including the organization of work duties, organization-specific
work demands and significant changes and events relevant for the composition of the
questionnaire and interview guide. Prior to the data collection, one of the researchers
participated on staff meetings at each unit to present the study and give practical
information about participation. Questionnaires in paper format were put in an envelope
together with a letter of information and an informed consent form, and placed in
each employee’s personal shelf at work. An inquiry concerning interview participation
was placed in selected personal shelves. Filled-in questionnaire and informed consent
form were to be returned in a provisional sealed mail box placed in the staff room
within two weeks. Two reminders were sent by letter to increase participation. Respondents
and informants were remunerated with NOK 200 (=27€) and NOK 300 (=41€), respectively.
The data collection was carried out between March 26 2009 and June 17 2009, and was
finally closed on June 29 2009. The study was approved by the Municipal Executive,
the Regional Committees for Medical and Health Research Ethics (REC) (no. 4.2009.19)
and Norwegian Social Science Data Services (NSD) (no. 21036).

Data collection

The questionnaire comprised altogether 129 items. The present study utilizes self-formulated
items regarding perceived changes in working conditions the last 5 years. The respondents
were asked to compare the present situation to the past with regards to perceived
time pressure. Response categories ranged from 1 (considerable less) to 5 (considerable
more) with a neutral mid-point, recoded to a three-point response scale (“less”, “no
change” and “more”). The respondents were also asked to evaluate the success of local
work environment interventions with four response alternatives; ‘a failure’, ‘less
good’ , ‘quite good’ , ‘a success’ , recoded to a dichotomous variable; “no effect”
and “positive effect”. IBM Statistical Package for Social Sciences (SPSS) version
19 was used to compute frequency distributions. Finally, open-ended questions on significant
positive and challenging changes affecting the work situation where respondents could
submit self-formulated responses were also included.

Seventeen semi-structured, in-depth interviews were carried out with Registered Nurses
and Enrolled Nurses. The interviews lasted approximately 1 hour and were audio-recorded
and later transcribed verbatim. The interview guide was based on initial conversations
with unit leaders and municipal representatives, and covered topics concerning work
environment, work tasks, and perceived changes in such the last years. The paramount
questions were “How do you perceive your work situation today?” and “How do you perceive
changes in your work situation to affect you and your work?” Main questions were followed
by probe questions such as “Can you give an example of this?”, “What do you think
caused this?” and so on to stimulate rich descriptions.

Annual sick leave statistics from 2004–2009 for each unit were accessed from the municipality’s
records, and contextual information regarding significant events and changes taken
place the last 7 years was gathered through interviews with representatives of the
municipal secretariat and unit leaders.

Qualitative analysis

The open responses in the returned questionnaires were organized to identify topics/categories
related to perceived changes in the work situation. As the majority of these responses
were briefly formulated, organization and categorization was straightforward. The
interview data were analysed by Template Analysis [28,29] producing a hierarchical list of codes representing themes identified in the interviews.
The software QSR NVivo 9 [30] was utilized to aid in organizing and examining the data. The interview guide served
as basis for an initial template consisting of three higher-order themes: 1) “Appraisal
of work situation” with the sub-themes “sources of stress” and “sources of job satisfaction”;
2) “Changes affecting the work situation” with the sub-themes “organizational changes”,
“work environment interventions” and “production system rationalization”, and finally
3) “Consequences” with the sub-themes “individual level” and “group- and organizational
level”. The analysing process of the interview data was carried out by identifying
higher-order themes and further scrutinizing the contents of these themes to identify
and differentiate lower-order themes. Accordingly, the initial template was somewhat
modified throughout the analysing process, resulting in a final template presented
in the Results section. This final template served as basis for interpretation and
illumination of the data, in line with recommendations by King [28].

Results

Figure 1 shows a chronological summary of significant events for the HCWs in the municipality
from 2003 to 2009. Campaign-related actions are reflected on NLI and municipal levels,
yet separate events initiated on municipal level with consequences for local units
are reflected on both municipal and unit levels. Examples involve mergers for all
units (some repeatedly), changes to middle management and executive management, organizational
changes such as the introduction of new technology, new work programs, and restructuring
by separating the home help service and assisted living institutions from the HCS (i.e. HCWs should no longer
attend to non-medical needs or to care recipients living in institutions). All of
these changes impact on work tasks, work duties and workday organization of the HCWs.

Figure 1.A chronological timeline of significant events taking place in the municipality from
2003 to 2009. Note: 1Separating home help (practical tasks) from home care resulting in pure professional
caring tasks. 2Change of name from “Health and care services” to “Health and welfare services”. 3Risk assessment resulting in 4interventions as described in Method section. 5Implementation of interventions on municipal level affecting all units included the
establishment of a safety patrol, temporary staff recruitment service and staff uniforms.
Implementation at unit level involved improved work routines and organization of work,
more equipment and facilities etc. 6Quality-enhancing work programme involving specification of new work duties and responsibilities
concerning the everyday life of patients living at home. 7Introduction of a Personal Digital Assistant involving changes in work procedures,
acquiring of new skills etc. 8Assisted living institutions separated from the Home Care Services resulting in pure
home care. 9Quality-enhancing work programme involving specification of new work duties and responsibilities
concerning patients’ discharge from hospital and return to home. 10Unit mergers in all cases involved new work office, leader, colleagues, geographical
area, care recipient group, budget figures, work routines, organizational culture
etc. 11Leader quitting in all cases involved a turbulent period of stand-in leaders before
the hiring of 12new leader. 13New geography involved new patients and greater geographical distances of transferring.

Sick leave statistics for each unit and the total sample are shown in Figure 2. Statistics from 2003 are not included as rates are incompatible due to the implementation
of a new basis for statistics, and a marked reorganization of the home care units
(from 21 to 11 units). A general tendency of increasing sick leave is observed, with
detectable differences between the units. Marked inflections in the sick leave of
units are labelled and commented in the figure legend. Clear, sustained differences
in sick leave between units were noted and attempted understood in interviews, yet
no firm explanation of these differences emerged.

A large majority (79.2%) of the HCWs perceived an increase in time pressure over the
last 5 years, with unit assessments varying from 100% (unit E) to 61.9% (unit D) (Figure 3A). Further, 65.3% of the HCWs considered the work environment interventions to have
had a positive effect in improving their work situation. This evaluation also varied
among the units, ranging from a high 89.5% positive (unit D) to a low 25% positive
(unit E) (Figure 3B).

Figure 3.Frequency distribution of (A) perceived change in time pressure over the last 5 years,
and (B) evaluation of intervention effect, for the total sample and for the individual
units.

By inspecting Figures 2 and 3, some units stood out by more positive assessment of the work environment interventions
(units A, C, D) and also recorded lower sick leave (units C, D). Others perceived
more time pressure (unit E), recorded high sick leave (unit E), and less positive
intervention effects (units B, E, F).

82 HCWs responded to the open questions on changes that have affected their work situation
in positive (n = 55) and challenging (n = 70) directions. Many of them listed several
changes, for a total of 178 comments. Comments concerning positive changes were intervention-related,
emphasizing improved organization and more available equipment and facilities. Comments
identifying challenging changes were closely intertwined and dealt with categories
related to increased exposure (time pressure and workload), implicit health consequences
of increased exposure (high sick leave), as well as perceived causes of increased
exposure (organizational changes, large units, budget cut-backs and tighter time allocations).
As these categories were closely connected to the qualitative interview findings presented
below, they were merged into Table 1 by showing number of open comments in the questionnaire corresponding to template
themes.

Table 1.Final coding template of interview data with quotes, examples of descriptions and
numbers of responses to open survey questions corresponding with interview data

Qualitative research findings

Table 1 shows the final template, presenting interview findings in terms of higher-order
themes and lower-order themes illustrated by quotes and examples of descriptions presented
by the HCWs. Three higher-order themes emerged in the data: 1) strenuous work situation,
2) changes affecting the work situation, and 3) consequences of strenuous work situation,
with several lower-order themes developed within each of them.

Strenuous work situation

Several distinct sources of a strenuous work situation emerged from the interviews.
All of the informants spontaneously described their work day as busy, hectic, stressful,
and characterized by a constant fight against time. Time pressure was generally considered
to be the most strenuous work factor, manifesting itself as physical, mental and emotional
strain. Several informants pointed at a negative trend towards increasing time pressure,
consistent with the assessment presented in Figure 3(A). Five themes relating to organizational demands (“placeholder code”) perceived
to cause a strenuous work situation emerged, all considered to result in work overload
and time pressure. Work lists consisting of descriptions of work tasks and visits
to be carried out, including specified time estimates, were described as exceeding
realistic expectations. Several specified tasks/visits were listed as to be carried
out simultaneously, and tight time allocations allowed no tolerance for extraordinary
incidents. Patient characteristics were described as becoming more demanding as patients
were sent home from hospital at an earlier stage of recovery. Some patient groups
(e.g. drug abusers and psychiatric patients) needed time that exceeded the standardized
time allocation, disarranging the time-specified work lists. Distribution of work
lists containing unexpected elements (e.g. new patients or new geographical areas),
which occurred due to tight budgets and restricted hiring of stand-ins, further induced
work overload and delays. Unexpected incidents were described as happening quite frequently,
without the system taking such incidents into account. Activities indirectly related
to patient care were described as an increasing source of work strain. These were
not specified tasks in the work lists and thus perceived not to be covered by allotted
resources. Overall, such organizational demands led to an increasing strenuous work
situation for the HCWs.

The informants further described strain due to conflicting work demands, in particular
the conflict between internal and external demands. They expressed clear self-directed
expectations of how the job should be performed, often involving compassionate activities
beyond what was stated in the individual agreement concerning what medical help the
patient is entitled to receive. These expectations were perceived to be in contrast
to requirements directed from municipal level focusing on rapidly carrying out professional
nursing activities at the expense of caring activities.

Changes affecting the work situation

When asked to compare the present work conditions to the situation 5–6 years ago,
all informants described a negative trend of increased workload, counter-productive
organizational changes and budgetary constraints. A fourth theme, work environment
interventions, was described in positive terms by some of the informants, but this
topic had to be probed to generate a response and descriptions were two-edged. All
informants described a tendency towards more challenging work situation characterized
by increased workload and higher work pressure with less time available. The further
elaboration of causes for this trend coincided with descriptions already put forth,
such as more demands of indirect time activities. Higher efficiency demands were described
in terms of work tasks being more specified and standardized, and time allocated to
specific work tasks being reduced.

Informants of all units exposed to merger in the study period (all but unit C) described
this change as resulting in a more challenging work situation. Stress-inducing effects
were related to both process issues and consequences. Unit mergers were perceived
motivated by cost saving and not rooted in concern for patients or employees. Over
all, budgetary constraints were considered as the antecedent of several processes
resulting in impaired working conditions, and the situation was perceived to get worse
every year. Economic deficits, causing restrictions to hiring temporary workers and
filling vacant posts, were perceived to generate increased workload and sick leave.

Work environment interventions that describe positive changes emerged as a theme after
explicit probes. Improved organization of work lists, additional equipment such as
cars and telephones, and improved routines for cooperation were described as effective
initiatives in reducing work strain. However, some informants couldn’t think of any
specific intervention for improved work environment, and a few HCWs were more pessimistic
in their descriptions, explaining how the interventions diverted time and money from
the unit, were not followed up due to lack of time, were withdrawn due to lack of
resources or the new situation was lapsing back to the former situation.

Consequences of strenuous work situation

The informants described several destructive consequences of strenuous working conditions
and negative changes to the work situation, which thematically could be distinguished
as being on individual level or on group- and organizational level. On individual
level, the majority of informants described how their health had been impaired due
to work-related stress and worries, but also because of wear and tear injuries. Frequent
descriptions included exhaustion, tension in neck and shoulders, headaches, back pain,
and strain injuries. The informants described reduced job performance with deteriorating
service quality as a consequence. On group- and organizational level, the informants
described how high sick leave was a twofold problem for the units. It was regarded
as a symptom of a strenuous work situation due to substantial pressure and onerous
organizational changes, and a source of additional strain on the remaining workers
because of work overload. With increasing work pressure due to restricted filling
of vacancies, informants described how the atmosphere would get affected when co-workers
call in sick. A few informants described how the work environment had improved due
to the interventions, yet most informants described negative effects on the work environment
in times of stressful peaks. Unit mergers and larger unit sizes were perceived to
result in work environment commotion and over-complexity.

Discussion

The results of this study confirm the initial hypothesis and thereby the assumption
implicit in the study aim: on-going rationalization measures interact with work environment
interventions and lessen the impact of these, highlighting the multiple processes
that determine working conditions of HCWs. The NLI initiated work environment interventions
were in general perceived to have a positive effect by improving targeted areas identified
to cause unhealthy time pressure and work strain. In parallel, new sources of time
pressure that negate the positive effects of work environment interventions were introduced.
The result is an overall worsening of the work environment. The documentation of the
many processes involved in managing the HCS supplemented by detailed worker descriptions,
provides a basis for a better understanding of their overall effects on work environment,
and provides a case-based example of how ergonomic and stress interventions can fail.

Figure 4 presents a graphic summary of the results: A number of drivers for change are listed,
including the NLI campaign to reduce time pressure, but also powerful drivers unrelated
to the work environment efforts of the municipality. These include costs control and
incentives to improve service quality. These drivers are omnipresent and have strong
and continuous effects on work organization and workload, symbolized by bold-faced
arrows. Measures to improve the work environment had positive effects on working conditions
of HCWs; as such, the municipal responses to NLI orders were successful. However,
the NLI campaign did not address the many changes to working conditions carried out
independently, and had the flavour of a one-off effort, supplementing the traditional
health and safety activities, but was not properly sustained over the study period.
Simultaneous production system rationalization measures had powerful negative consequences
on workload, and tipped the balance towards more difficult working conditions. External
changes to the organization of the health service with early discharge from hospitals
resulted in more demanding patient characteristics, and regulatory framework and outside
pressure pushed for improved quality of care. Such demands were met by traditional
productivity-enhancing management actions; foremost among these were standardization
measures. Consequently, time pressure and work stress were perceived to increase over
the study period. The resulting health effects of work strain for this group of HCWs;
musculoskeletal complaints, have been documented elsewhere [21]. Finally, a feedback loop is indicated: municipal stakeholders respond to high sick
leave and other indicators of work overload by attempting to improve working conditions.
Such supplementary work environment measures in general do not relate to work content
determinants that result from efficiency measures. The overview in Figure 4 is not unique, several studies propose organizational changes or turbulence unrelated
to an intervention as a plausible explanation of lack of positive results [3,6-9] and conversely, that organizational stability is a prerequisite for interventions
to succeed [5]. However, the present study aims to demonstrate a more nuanced documentation of critical
factors and processes implicit in causing an unfavourable outcome.

Figure 4.Graphic summary of results. Note: Dashed line symbolises a distinction of the two concurrent processes in the
organization of the HCS, and a putative lack of consideration and inter-level communication
of work environment effects for HCWs. Bold arrows indicate dominant processes. Plus
and minus signs on arrows indicate increasing and decreasing effects on workload,
respectively.

Most positive intervention-related changes identified by the HCWs were of a specific
character, and were directly related to areas identified as risk factors of unhealthy
time pressure, implying that interventions successfully hit targeted areas (e.g. buying
more cars, sorting out work lists). However, the overall effect of the work environment
interventions seemed small in comparison to powerful effects of the rationalization
measures.

Restructuring by separating practical home help from the HCS was part of a process
that allowed further standardization of specialized caring work duties. Although intended
to reduce work stress by removing ‘disturbing’ tasks such as house cleaning and grocery
shopping, it may conversely have led to increased work intensification by reducing
work porosity as such practical tasks often were postponed in situations with high
time pressure. Workers providing nursing care in other studies report significantly
more strain than workers providing personal care [31]. The standardization of work duties allowed work lists to be more precise in describing
each work task with corresponding time allocation, making work tasks more efficiently
allocated and resulting in more hectic working conditions. More visits of shorter
duration also generate more indirect-time demands (transport, documentation), which
was not time-compensated: the overall time allocated to caring tasks as specified
on work lists was not reduced. This is in accordance with other studies referring
to fragmentation of care time and increasing time pressure as the core problems facing
HCWs [14]. Standardization measures in this study is an example of a trend towards a Taylorising
type of care, operationalized by a specified amount of minutes to fragmented physical
work tasks (e.g. putting on support stockings should take 5 minutes), and valuing
instrumental care over affective care [32]. HCWs in the present study described how being in a constant hurry prevented them
from yielding affectionate care, causing emotional strain and health complaints by
feeling unable to yield sufficient care [21]. Into the study period the municipality changed the health division’s name from “Health
and Care Services” to “Health and Welfare Services”, signalling the elimination of caring aspects. Cloutier, David, Ledoux,
Bourdouxhe, Gagnon and Ouellet [25] refer to home care personnel experiencing an erosion of job content as the affective
aspects of their work are disappearing due to work intensification caused by restructuring.
It is hypothesized that the stakeholders who effectuated the standardization process
in this study, were not aware or chose to ignore the emotional aspects of HCWs work
duties, while they were fully aware of the need for productivity enhancing measures.
The interviews further suggest that other, more incidental “time thieves” (e.g. difficult
traffic conditions, patients requiring extraordinary care) were not properly recognized
in the standardization process. Such items are clearly dependent on context and probably
also on the individual HCW, and are difficult to integrate in time plans. Other perturbations
include extra patients on work lists due to HCWs calling in sick, a problem with workload
implications that may not be fully communicated to municipal administrators.

Documentation of work tasks is necessary in efforts to improve the quality of HCS.
However, administrative requirements were listed as a major contributing factor to
increased workload. Two new work programs introduced during the study period involved
significant increases in documentation needs. Service quality was to be increased
by introducing a “memory list” specifically stating what to observe, how to act and
what to document in a care recipient’s home. The HCWs experienced that work duties
related to these programs resulted in additional work tasks at the expense of traditional
caring tasks, and as they mainly involved duties indirectly related to the care recipients
and presumably already carried out though in a less systematic manner, no extra time
was allocated. Cloutier, David, Ledoux, Bourdouxhe, Gagnon and Ouellet [25] refer to such administrative responsibilities as ‘invisible tasks’ resulting in work
intensification as they are added without eliminating traditional tasks. Hence, these
two programs most likely introduced additional sources of time pressure for the HCWs.
Likewise, the implementation of new technology, a Personal Digital Assistant (PDA)
required new skills and new working methods, likely contributing to additional work.
One rationale behind the introduction of the PDA was that by having information available
at all times and writing reports immediately after an assignment, waiting time for
access to a computer would be reduced. The flip side involved a stated intention of
increased efficiency as ‘time waiting in line’ (“waste” in rationalization terms)
would be reduced.

A rationale for restructuring the organization by separating the assisted living institutions
from the HCS and merging pure home care units, was to increase quality by making the
services more specialized and to save costs by reducing the need for administrative
personnel. Larger units were assumed to be more robust and less sensitive to disturbances
such as unexpected sick leave. Organizational change in terms of unit mergers is accepted
to be a stressful experience for employees, and the human costs of such mergers is
put forward as one explanation as to why so many mergers fail in reaching their stated
objectives [33-35]. During the study period, all six units underwent mergers, two of them repeatedly.
The HCWs expressed merger-related stress both with the change process itself and with
the subsequent consequences: increased time pressure was attributed to larger unit
sizes, greater geographical distances, establishment of new roles and ways of cooperating,
and culture clashes. These factors remained disruptive elements independent of the
work environment interventions. HCWs who worked in small units forced to merge with
larger ones, were particularly vulnerable to merger-related stress. For them the merger
implied a new work situation involving new office, new colleagues, new leader, new
geographical areas with new care recipients, new work routines, new organizational
culture, new budget figures etc. Two marked peaks in the sick leave statistics (units
A and E) appear to reflect strain upon merger, by correspondence in time and by the
qualitative data. Previous research has linked organizational downsizing to sick leave
[36], but strong associations have also been found between workplace expansion and sick
leave [37].

The discussion has considered factors that may explain the disappointing outcome of
the NLI initiated interventions; a relevant question is why the negative development
is allowed to happen: a sick leave of nearly 20% is clearly a worry for all parts
involved. At one level, it is clear that financial and quality considerations are
given priority, while workload consequences of rationalization interventions may not
be fully understood. Findings suggest that stakeholders on higher organizational levels
do not have intimate insight in work demands on HCWs, and that commonly used work
descriptors may differ in content by organizational level (manuscript in preparation).
The responsibility for good working conditions and budget managing reside with the
unit leaders, and may involve conflicting concerns. Municipal staff being two organizational
levels removed (unit leader being the intermediate level), may be too distant from
the ‘shop floor’ to manage the integration of work environment concerns with the concern
for effective production of high-quality services. Disruptions to work duties due
to organizational restructuring may not be fully understood. Better insight in the
interruptive influences of rationalizations would be beneficial to stakeholders; such
insight may exist at the intellectual level, but is not necessarily internalized so
that it can be incorporated when planning changes to the production system. Improvement
in two-way flow of information and inclusion of HCWs in the planning and implementation
of production system rationalizations seem a key ingredient in preserving good work
environment while accommodating (necessary) productivity-enhancing measures.

Some units seem to benefit more from work environment interventions while others suffer
more from rationalizations. It has not been possible to identify trustworthy explanations
of between-unit differences in responses. However, differences in the way unit leaders
have dealt with change processes (e.g. information flow, employee participation, handling
employee reactions) and change consequences (organization of enlarged units, culture
clashes, training) have likely affected perceived exposure effects and subsequent
consequences [1], and may explain such variations. Leader stability and the implementation of interventions
likely varied across the units. Other between-unit factors include geographical extension
(impacting on transferring distances) and patient characteristics (psychiatric diagnosis
and drug addiction more densely populated in certain areas), both involving work time
exceeding allocations. Finally, considerable unit variations in excess spending and
budget deficit caused variations concerning practice of hiring temporary staff when
sick leave, and may explain variations in perceived overload and time pressure. Sustained
differences in sick leave between units imply a potential for developing ‘best practice’
management at unit level, an opportunity that should be explored.

The use of mixed-methods design in this study is in accordance with recent methodological
recommendations revolving around the need for a more eclectic and complementary approach
in order to understand the process issues in intervention research [5,9,11,38]. In the present study, a comparison of sick leave rates or of quantitative measures
pre and post intervention without including qualitative interviews, open-ended survey
questions and the documentation of concurrent changes would have yielded insufficient
and incorrect results regarding intervention effect. Programme or theory failure and
implementation failure [9] are common suggestions to disappointing intervention results and could have been
wrongly set forth as explanatory factors. Also, the units have changed to such a degree
that a comparison would not have been meaningful. Turnover or changes in staff compositions
may pose potential problems when comparing sick leave development within and between
units. Changes to the extent demonstrated in this study are the rule rather than the
exception in today’s working life. Generalizability of the present results is limited
due to the nature of case studies. However, general principles regarding the interference
of concurrent changes during interventions as posited in Figure 4 appear valid for most organizations and can be transferred to branches outside health
care. Whereas most studies mention the interfering role of concurrent changes in an
anecdotal manner, this study adds to the existing literature by systematically examining
significant changes and events over a 7 year period, and elaborates on these elements
by including worker perspective through qualitative methods. Open-ended survey responses
and interview descriptions were strongly accordant, strengthening the trustworthiness
of the findings. A historic prospective design may involve certain pitfalls such as
memory bias or an overestimation of informants’ abilities to reflect on the impact
of past incidents. However, this sense-making process is necessarily a retrospective
activity [39].

Conclusions

Concurrent production system rationalization measures resulted in negative work exposure
effects that negated positive effects of a comprehensive work environment intervention
program carried out in the HCS in a Norwegian municipality. Substantial contextual
instability occurred during the intervention period, such as new work programs and
several organizational changes with implications for work duties, work content and
workload. As change and restructuring for improved performance are inevitable parts
of organizations’ lives, it is necessary to be aware of work environment consequences
of such activities. It is recommended to establish and actively utilize communication
channels from workers to middle and top-level management to increase awareness of
putative harmful effects of rationalization measures.

Competing interests

The authors have no conflicts of interest or competing financial interest to declare.

Authors’ contributions

GRA participated in the design of the study, the collection of data, analysis and
interpretation of data, and drafting of manuscript. RHW participated in the design
of the study, interpretation of findings, and drafting of manuscript. Both authors
read and approved the final manuscript.

Acknowledgements

We are grateful to the home care workers who participated in this study and to the
Norwegian Labour Inspectorate for partial support.

Ono Y, Lagerström M, Hagberg M, Lindén A, Malker B: Reports of work related musculoskeletal injury among home care service workers compared
with nursery school workers and the general population of employed women in Sweden.